Genital gender-affirming surgery: a history from the shadows to the forefront

Gender dysphoria is characterized by a discrepancy between an individual’s gender at birth and the gender with which they identify themselves. Gender-affirming surgery encompasses a variety of procedures that aim to alleviate gender dysphoria. These are broadly divided into “top surgery” or “bottom surgery” for both birth-assigned females being affirmed as males (FTM) as well as birth-assigned males being affirmed as females (MTF). Bottom surgery refers to a number of inter-related procedures with a goal of genital reconstruction in transgender patients. In FTM patients, this focuses on phalloplasty, or the creation of a penis. In MTF patients, bottom surgery largely signifies vaginoplasty, or the creation of a vagina. Genital reconstruction, along with gender-affirming surgery overall, has a unique and interesting history.

The first studies focusing on transgender individuals were published in the nineteenth century. In the United States, widespread attention on the transgender community was not received until 1953 when Christine Jorgensen, a World War II veteran, underwent gender-affirming surgery in Copenhagen. By 1966, Dr. Harry Benjamin published The Transsexual Phenomenon, which advocated for gender affirming surgery, rather than conversion therapy as was advocated by many who felt gender dysphoria represented a mental illness. During the 1960s, multiple centers throughout the country, with Johns Hopkins being the first, opened clinics for transgender individuals seeking gender-affirming surgery. The number of centers as well as private surgeons performing such procedures has since continued to rise.

Genital reconstruction for MTF patients, again largely representing the creation of a new vagina, has its roots in he nineteenth century as similar procedures at that time were described in female patients with congenital, traumatic, or surgical wounds of their vagina that required reconstruction. The first MTF patient to undergo documented vaginoplasty was Dorchen Richter in 1931. The first high profile case was the case of Christine Jorgensen in 1953, which was performed using a skin graft from the penis that had been removed during the same procedure. Prior to this, vaginal reconstruction was largely performed with skin grafts from the back, buttocks, or thigh. In the 1950s, the technique of penile inversion vaginoplasty was first described and performed. In this procedure, which has largely become the most common method in current practice, the penile skin is freed and inverted internally to create the new vagina. This technique may be supplemented as needed with additional skin grafts. A less common method of vaginoplasty involves using a piece of intestine to create the vagina.

Gender-affirming surgery for FTM patients involves the creation of a penis (phalloplasty) with ultimate goals of allowing for urination while standing as well as for sexual penetration. The first description of such procedures for gender affirming surgery is by Sir Harold Gilles in the 1940s in which he used tissue from the patient’s abdomen to perform the phalloplasty. These phalloplasty techniques using nearby tissue that stayed connected to either the abdomen or thighs remained popular through the 1970s. Notably, the first documented case of FTM phalloplasty in the United States was performed in the 1960s. During the 1980s, various other methods for phalloplasty were described, although initially they were performed largely for males with penile injuries. These included using distant tissue from the arms, legs, or back to create a new penis. Over the years, these procedures have been performed more commonly, although they remain plagued by various issues with many surgeons working to improve outcomes.

Overall, genital reconstruction for gender-affirming surgery is a challenging surgical field that aims to alleviate gender dysphoria in transgender individuals. Gender-affirming surgery possesses a unique historical perspective through which progress in today’s modern era can be viewed.

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